Mineral City woman fights back after liver transplant is denied by insurance

Insurance companies handle millions of claims a year; the majority of the time, they are approved. But sometimes they're not, putting sick patients and their families in the unwelcome position of turning to the company for an explanation. Mineral City's Bonnie Patrick was one of the unfortunate few.

Editor’s note: This is first part of Bonnie Patrick’s journey through a cancer diagnosis and her pursuit of a liver transplant. Read the rest on Tuesday.

Sometimes no isn’t the final answer.

Insurance companies handle millions of claims a year; the majority of the time, they are approved. But sometimes they’re not, putting sick patients and their families in the unwelcome position of turning to the company for an explanation.

Bonnie Patrick of Mineral City knows that all too well.

Her claim for a liver transplant was initially denied. Though the procedure was eventually approved, the denial delivered added anxiety during an already difficult time.

“I just don’t want it to happen to everyone else. I don’t want anyone else to go through this — the emotion, the stress,” she said.

“DEVASTATING”

Patrick, 60, never was sick. At a routine doctor’s appointment in May 2013, she mentioned that she’d had a pain in her side for several weeks.

Her doctor thought it was kidney damage, perhaps caused by blood pressure medication, and ordered tests.

It wasn’t.

She had months of procedures and testing, doctors found one tumor, then eight, then 20. The Cleveland Clinic removed two of the largest tumors and confirmed the worst. Her official diagnosis: Neuroendocrine cancer.

Patrick had surgery in December to remove parts of her intestine and three lymph nodes. The next step was going to be radiation. As a last resort, she’d need a transplant.

The cancer had destroyed her liver. That last resort became her only option.

Her family was in shock.

“It was devastating,” said Nicole Dugan, of Strasburg, Patrick’s daughter.

“You go from not having cancer in June, to thinking it’s just an infection, to October, you have cancer, to January, you’re having a liver transplant,” Patrick said. “It’s just so much at one time.”

One of the hardest parts was knowing that she’d never had any symptoms. If she’d never complained about that pain, they wouldn’t have found the cancer, she said.

TRANSPLANT

Being approved for a transplant isn’t quick or easy.

It requires a variety of testing, endless blood work, and days of consultations with various experts. The Cleveland Clinic’s Liver Transplant Selection Committee has to approve the patient. Once they sign off, the Ohio Solid Organ Transplant Consortium Liver Transplant Review Committee also has to agree.

Patrick was approved for her transplant in April. Dugan, 32, who immediately volunteered to be a donor the first time a transplant was mentioned, was scheduled to be evaluated April 14.

Page 2 of 3 - Then everything came to a halt. Patrick got a letter April 11 from her insurer, AultCare, saying that her transplant was denied. The procedure was deemed experimental and not medically necessary.

“Never one time did we think that the insurance company was not going to approve me,” she said.

Up until then, AultCare had covered everything, Patrick said. She had few out-of-pocket expenses and the company had approved, without question, all of the testing beforehand.

“I was just totally devastated. I thought, if I don’t have insurance, I’m not getting this transplant,” Patrick said.

She was also baffled at the explanation for denial.

“Cleveland Clinic is the best hospital there is. If they say you need a liver, you need a liver,” she said.

DENIED

AultCare, based in Canton, has about 423,000 clients and handles tens of thousands of claims a year.

The company receives about 30 requests for transplants a year and 99 percent are ultimately approved, said AultCare spokesman Mike Gallina.

Each patient is unique and their cases have different considerations, he said, but all transplants must go through the same approval process, starting with being OK’d for initial testing to see if a transplant is even an option.

Once a patient has undergone testing and is approved, the provider — in Patrick’s case, the Cleveland Clinic — submits a request to AultCare along with clinical information on the patient. At that point, an objective third-party specialist in the same clinical field reviews that information and makes a determination.

A patient could be denied because they aren’t a good candidate for a transplant or, like in Patrick’s case, because the procedure is deemed experimental or not necessary.

AultCare can’t cover a procedure that’s not scientifically sound, said Tiffany Good Witmer, a registered nurse and vice president of care coordination for AultCare.

“We make all clinical decisions based on evidence-based scientific criteria,” Witmer said, adding that the criteria is based on nationally accepted standards.

“It doesn’t mean that we don’t care about the patient — we have a lot of empathy for these patients and really do everything we can to help get these approved — but it has to meet that criteria in order for it to be approved,” she said.

AultCare can’t deny a claim for any other reason, such as expense, she said.

If the procedure is denied, the patient and provider are sent a letter notifying them of the denial, the reason why, and their right to an appeal. Patients and providers can appeal, Witmer said.

Page 3 of 3 - Under federal law, you have the right to an internal review if your insurance company denies payment for a treatment or service. If that internal review still results in a denial, you have the right to an independent external review that could overturn the denial, according to Department of Health and Human Services.

Ohio law also requires an internal and external review process.

If that external review still results in denial, you may be able to file a civil suit, according to information from AultCare.